Maternal Third Delay and Associated Factors among Women Admitted for Emergency Obstetric Care in Public Hospitals in Sidama Regional State, Ethiopia

Background Timing to get obstetric care is critical in preventing maternal death and disability. Maternal third delay, the delay in receiving care after reaching health facilities, involves factors related to organization, quality of care, patient referral, and availability of staff and equipment. However, data is limited on maternal third delay and its associated factors at higher health facilities in Ethiopia. Objective This study is aimed at assessing the magnitude of maternal third delay and associated factors among women admitted for emergency obstetric care in public hospitals in Sidama Regional State, Ethiopia, 2021. Methods An institution-based cross-sectional study was conducted from September to November 2021. Face-to-face interview with a structured questionnaire and data extraction from medical charts were carried out in selected 542 women (using systematic sampling method). The collected data were coded and entered using EpiData, and bivariable and multivariable logistic regression analyses were done using SPSS version 25. Statistical significances were declared at p value less than 0.05. Results Maternal third delay was identified among 29.3% (95%CI = 25.2 − 33.5) of the respondents. Additionally, women who arrived with a referral from other health facilities (AOR = 0.311, 95%CI = 0.181 − 0.534), well prepared for birth and its complications (AOR = 2.418, 95%CI = 1.51 − 3.869), self-employed (AOR = 0.223, 95%CI = 0.122 − 0.409), being a government employee (AOR = 0.157, 95%CI = 0.063 − 0.396), having ANC follow-up (AOR = 2.795, 95%CI = 1.318 − 5.928), and absence of health professional (AOR = 4.63, 95%CI = 2.857 − 7.50) were significantly associated with maternal third delay. Conclusion This study identified that maternal third delay was high, which indicates that women have not received emergency obstetric care in the recommended time range after they arrived at the health facilities.


Introduction
Timing to receive emergency obstetric care is critical in preventing maternal disability and death. The three delays model, which was developed by Thaddeus and Maine in 1994, enables us to identify indirect factors that contribute to maternal death. This model identifies three critical phases: first delay, delay in the decision to seek care; second delay, delay in identifying and reaching the health facility; and third delay, delay in receiving care at the health facilities [1].
Maternal third delay includes drugs and equipment, policies and guidelines, human resources, facility infrastructure, patient-related, and referral-related [2,3]. The contribution of maternal third delay to institutional maternal death and disability either alone or in combination with other phases of delays was high [4,5]. Addressing this type of delay, which involves factors within the health facility, is essential for ensuring that obstetric emergencies are efficiently managed [6,7].
Currently, there is a paradigm shift from the first and second phase delays to the third phase delay as the main contributor to maternal mortality [4]. In Ethiopia, the Maternal Death Surveillance Report (MDSR) analysis showed that delay three was cited in 48.6% of the total report of maternal deaths which was higher than the previous year's report [8]. Different factors to receive care in health facility impact not only the outcomes at the facility level but also in the community by providing feedback for subsequent decision-making to utilize emergency obstetric care [2].
Women who need emergency obstetric care experience extremely long delays after reaching a health facility [9]. A multicountry study done in seven countries (Ethiopia, India, Indonesia, Nigeria, Tanzania, Uganda, and Nepal) found that there was a high level of care seeking for maternal complications in the community. Conversely, there was a significant gap around the provision of maternity services, which needs urgent action to improve it at facility level [10].
Different studies identified that inadequate infrastructure and supplies including bed drug supplies, insufficient health personnel [11,12], refusal to get treatment, limited ability to pay for different costs despite national policy to provide free service [13,14], unprofessional behavior of health care providers, and weak coordination of referrals were barriers to maternal health service utilization that results in delay in receiving emergency obstetric care [11]. In Ethiopia, previous studies showed that the magnitude of maternal third delay was 32.6% in Nigist Eleni Mohammed Memorial General Hospital [15], 26.9% in three referral hospitals (Felege Hiywot, Debre Markos, and Debre Birhan Referral Hospital) of Amhara Regional State [16], and 74.7% in two referral hospitals in Addis Ababa [17]. Since there was limited data about the magnitude of maternal third delay and its associated factors in higher health facilities of Ethiopia, this study was aimed at assessing it in public general and specialized hospitals in Sidama Regional State.

Method and Materials
2.1. Study Setting. This study was conducted in four public hospitals located in Sidama Regional State, Ethiopia, that were general and comprehensive specialized public hospitals within the regional state. The regional state has a total of 18 public hospitals, one comprehensive specialized public hospital (Hawassa University Comprehensive Specialized Hospital), four general hospitals (Adare General Hospital, Bona General Hospital, Leku General Hospital, and Yirgalem General Hospital), thirteen primary hospitals, and one hundred and thirty-three health centers [18].
Based on each hospital monthly report, which was found from Regional Health Bureau and each hospital registration, the six-month (March to August 2021) report preceding the survey showed that on average, 352, 285, and 236 women were admitted every month for emergency obstetric care in Hawassa University Comprehensive Specialized Hospital, Adare General Hospital, and Yirgalem General Hospital, respectively.

Study Design and
Period. An institution-based, crosssectional study was conducted in general and comprehensive specialized public hospitals in Sidama Regional State from September 13 to November 13, 2021.

Source Population.
All women who attended emergency obstetric care in public hospitals in Sidama Regional State were the source population.

Study Population.
All women who were admitted for emergency obstetric care in selected general and comprehensive specialized public hospitals in Sidama Regional State during the study period were the study population.
2.5. Eligibility Criteria 2.5.1. Inclusion Criteria. All women who were admitted for emergency obstetric care in the selected hospitals and those women who were volunteered to participate in the study were included in the study.

Exclusion
Criteria. Women who were readmitted after an earlier inclusion and those who were transferred to another facility after earlier inclusion were excluded from the study. Women who were unable to provide a response due to ill health status were also excluded from the study.
2.6. Sample Size Determination and Sampling Procedure 2.6.1. Sample Size Determination. The sample size of this study was calculated for both the magnitude and associated factors. However, larger sample was identified using the single population proportion formula considering the following assumptions: 95% confidence interval (CI), prevalence (p) of third delay 34.7% [19], the margin of error (d) 0.05, design effect 1.5, and adding 10% nonresponse rate; the final required sample size was 574.
2.6.2. Sampling Techniques and Procedures. Multistage sampling technique was used to draw participants from the study population. First, by using a simple random sampling method, two public general hospitals (Adare General Hospital and Yirgalem General Hospital) were taken from all four general hospitals (Adare General Hospital, Bona General Hospital, Leku General Hospital, and Yirgalem General Hospital) and Hawassa University Comprehensive Specialized Hospital was taken directly since there was no other comprehensive specialized hospital in the regional state.
Study participants were selected from the study population by systematic sampling, in which samples were withdrawn every K of admitted women on discharge. After calculating K ðN/nÞ, where "N" is the total number of women expected to be discharged from the hospital after they got emergency obstetric care in the study area during the study period (two months) based on the previous 6month statistics and "n" is the calculated sample size; study participants were selected at every K th interval (1746/574 = 3:04). Therefore, samples were taken every 3 rd interval. The first participant was selected by lottery method.

Absence of Health Professionals.
A woman was considered as she experienced an absence of health professionals when she reported that she did not get health professionals when she needed them during her stay in the current hospital admission [20].

Data Collection Tools and Procedures.
Data collection tool was adopted and modified after reviewing different literatures [20,25]. The referral paper, triage paper, and patient chart were reviewed about the woman's condition. Interview regarding sociodemographic characteristics, the reason for delay (if any), and her experience in the hospital was done using a structured questionnaire in the inpatient wards every day at the time of discharge.
2.9. Data Quality Assurance. Data quality was assured by developing a structured questionnaire in English based on the objectives to be addressed after reviewing the relevant literature, and it was reviewed by the principal and coadvisors. The translation of the questionnaire from English to Amharic and Sidaamu Afu (the local language) was done by a language expert. The data collection was done following two days of training for data collectors and supervisors (all were BSc Midwives) after the pretest was conducted with 5% of the calculated sample size at Shashemene General Hospital. Any ambiguous and unsuitable questions were modified after checking of questionnaire completeness at pretest. The collected data were checked by supervisors and principal investigators for its completeness.

Respondent's Characteristics Related to Obstetric Danger Sign Knowledge and Birth Preparedness and Complication
Readiness Practice. From the total 542 respondents, 300 (55.4%), 313 (57.7%), and 232 (42.8%) were identified as knowledgeable on danger signs during pregnancy, labor and delivery, and postpartum period, respectively. In addition, 333 (61.4%) of the study participants were well prepared for birth and its complications (Table 3).

Admission and Hospital
Stay-Related Characteristics of the Respondents. Three hundred one (55.5%) of the respondents arrived to the hospital during the day time, and 391 (72.1%) were during working days. Concerning the availability of health professional, 158 (29.2%) respondents reported that they did not get a health care provider as they need (Table 4).

Journal of Pregnancy
3.5. Magnitude of Maternal Third Delay. In this study, maternal third delay was identified among 29.3% (159) (95%CI = 25:2 − 33:5) of the study participants. Time to receive emergency obstetric care ranges from less than a minute to 6 hours, and the median time to receive care was 40 minutes with an interquartile range between 25 and 60 minutes. For descriptive purposes, the time to receive emergency obstetric care was separated into three phases. The first was the time gap between arrival to the health facility and triage, which was ranged from less than a minute to 1 hour and 30 minutes, and the median time was 10 minutes. The second phase was between triage and the first examination by a health professional, and it ranges from less than a minute to 1 hour and 20 minutes with a median of 6   5 Journal of Pregnancy minutes. The third phase, which was described as the gap between the first examination by a health professional and receiving care, ranges from less than a minute to 5 hours and 45 minutes, and the median was 15 minutes.

Reason for Maternal Third Delay as Described by the
Respondents. Based on women's reports, the top identified reason for maternal third delay was staff workload (47.2%). Additionally, long admission process 35 (22.0%), health professional negligence 27 (17%), and a problem with supply or medication 23 (14.5%) were also identified as the reasons for their delay in receiving care (Table 5).

Factors Associated with Maternal Third Delay.
In the results of bivariable logistic regression analysis, maternal third delay was associated with women's educational status; women's occupational status; decision-maker for obstetric care; knowledge on danger signs of pregnancy, labor and delivery, and postpartum; referral status of the women; ANC visit; BPCR practice; absence of health professional; lengthy admission process; date of admission; pregnancy status on admission; mode of termination of pregnancy; and experiencing obstetric complication with significance level of p < 0:25 (Table 6).
Women who experienced referral from health facilities were almost 68.9% (AOR = 0:311, 95%CI = 0:181 − 0:534) less likely to encounter maternal third delay compared to those women who get the service in their first contact visit. Similarly, women who did not find health professionals as they needed were five times (AOR = 4:63, 95%CI = 2:857 − 7:50) more likely to have maternal third delay compared to their counterparts.

Discussion
This institution-based study has attempted to identify the magnitude and associated factors of maternal third delay  Reason not mentioned 28 17.6 * Laboratory result delay, waiting for family member, and not identifying the ward. 6 Journal of Pregnancy in public general and comprehensive specialized hospitals in Sidama Regional State, Southern Ethiopia. The result showed that maternal third delay among women admitted for emergency obstetric care in public general and comprehensive specialized hospitals in Sidama Regional State was 29.3% (95%CI = 25:2 − 33:5), and it is in line with the study done in Gamo Zone (31.7%) [20], Arsi Zone (25.5) [26], Nigist Eleni Mohammed Memorial General Hospital (32.6%) [15], Bahir Dar City (30.7%) [27], three referral hospitals of Amhara Regional State (26.9%) [16], and Yem Special Woreda (34.7%) [19]. This might be for having similar health policy and strategy. However, in this study, the magnitude of maternal third delay is lower than the study done in two referral hospitals in Addis Ababa (74.7%) [17]. This difference might be due to variation in the study setting, sample size, population size, women's socioeconomic and demographic characteristics, fee-free services in the study area, advanced medical logistics supply, and professional staff. The two referral hospitals in Addis Ababa [17] provide services with fees, and the population size was incomparably high in contrast to the study area which may affect service provision.
In reverse, the magnitude of maternal third delay is higher than the study conducted in University Teaching Hospital of Ouagadougou (UTH-YO), Burkina Faso (8.2%) [28]. The reason might be the study was conducted in a single hospital. Additionally, the difference in health policy and having an improved maternal health profile in Burkina Faso might contribute for this result [29].
Based on women reports of their reason for experiencing delay in receiving care, staff workload 75 (47.2%), lengthy admission process 35 (22%), health professionals negligence 7 Journal of Pregnancy 27 (17%), lack of supply or drugs 23 (14.5%), delay in providing informed consent 3 (1.9%) and unfunctional operating room 2(1.3%) were stated. These findings were also identified as a reason for maternal third delay in a crosssectional study conducted in Brazil [30], University of Gondar Referral Hospital [31], Arsi Zone [26], and a multicountry study done in seven countries [10].
Women's occupational status, not receiving emergency obstetric care at the first contact visit (referred from another health facility), ANC follow-up, BPCR practice, and absence of health professionals were significant predictors of maternal third delay.
Women whose occupations were self-employed and government employees have 77.7% and 84.3% less likely to experience maternal third delay compared to housewives, respectively. This was consistent with the study done in Arsi Zone [26]. However, none of the sociodemographic variables were associated with maternal third delay in a study done in Bahir Dar City [27]. The reason for the lower maternal delay among self-employed and government employees might be these groups of women might have ANC followup and well prepare for birth and its complication [32]. Additionally, they might identify and report obstetric danger signs early.
Related to ANC follow-up, women who had no antenatal follow-up were three times more likely to experience a third delay compared to those who had one or more antenatal follow-up. Similar result was also found in a study done in Arsi Zone [26]. Additionally, a study conducted in West Bengal, India, also reported that women who did not attend ANC had a higher proportion of maternal third delay [33]. This might be for the reason that women who had ANC follow-up might be knowledgeable on obstetric danger signs and well prepared for birth and its complication [34]. Other possible explanations might be the experience of women to communicate with health care providers; and they might know to whom and how to communicate for their problems.
Regarding the absence of health professional, women who reported the absence of health professionals when they need them were five times more likely to have maternal third delay compared to their counterparts. This result is in line with studies done in Gamo Zone, Ethiopia, which identified that women who reported the absence of health professionals when they need them were ten times more likely to experience maternal third delay [20]. Additionally, this association was found in a study conducted in Hadiya Zone [15]. This might be for a reason that there might be a gap in the availability of health professional to give care due to staff workload and/or motivation.
Referral status of the women was another factor associated with maternal third delay. Women who experienced referral from health institutions were almost 68.9% less likely to encounter this type of delay than those women who got the service in their first contact visit. This result is in line with a study done in another study in Ethiopia which shows 80% less likely to experience this type of delay [15]. This might be for the reason that women who were referred from other health facilities might have obstetric complications for which human resources and supplies might be mobilized [26]. Additionally, the receiving facilities might be communicated before they refer the woman that might make the receiving hospital know the woman health condition and get ready to manage her health problem.
Additionally, BPCR practice was significantly associated with maternal third delay. Women who were not well prepared for birth and its complications were found to be two times more likely to experience this type of delay. This could be due to the reason that these women might solve problems related to financial issues when they encounter lack of supply or drugs and give consent timely; and they might also report obstetric danger signs early.
This study has certain limitations. Since the data were collected from women perspective and medical chart which might not be enough to describe maternal third delay in in-depth way, this could be improved with the inclusion of qualitative method and direct observational studies. Recall bias might also be a problem since women were asked about their experience. The utilization of secondary data might be a problem. Therefore, the interpretation of the findings should be made carefully.

Conclusion and Recommendation
This study identified that maternal third delay was high and several women were not receiving emergency obstetric care in the recommended time range after they arrived at the health facilities. Being government employed and selfemployed, having ANC follow-up, being well prepared for birth and its complications, arriving with referral from other health facilities, and absence of health professionals were significant predictors of maternal third delay. Therefore, it is better to incorporate the identified factors (women's occupation, referral status, ANC follow-up, BPCR practice, and absence of health professionals) during the implementation and evaluation of maternal health programs to decrease maternal third delay.

Data Availability
The data sets analyzed during this study are not available publicly due to privacy reasons but are available from the corresponding author on request with rational reason. 8 Journal of Pregnancy